A 20-year-old man is admitted to the psychiatric unit for treatment of acute schizophrenia and is started on risperidone (Risperdal). Which client effects should the nurse assess for to determine whether the drug is having therapeutic effects?

Clients on antipsychotic medications are at risk for both common and life-threatening adverse effects. While many side effects are uncomfortable but manageable, the sudden onset of certain symptoms may indicate a medical emergency such as neuroleptic malignant syndrome (NMS), which requires immediate intervention to prevent serious complications or death.

Rationale for correct answer:

A. Fever, tachycardia, confusion, incontinence – These symptoms suggest neuroleptic malignant syndrome, a rare but potentially fatal reaction to antipsychotics. NMS is characterized by hyperthermia, autonomic instability, altered mental status, and severe muscle rigidity. Immediate discontinuation of the drug, rapid medical management, and supportive care are critical.

Rationale for incorrect answer:

B. Pacing, squirming, or difficulty with gait such as bradykinesia – These are signs of akathisia or drug-induced parkinsonism, which are types of extrapyramidal symptoms (EPS). While uncomfortable and requiring prompt treatment, they are not typically life-threatening emergencies.

C. Severe spasms of the muscles of the tongue, face, neck, or back – This describes acute dystonia, an early-onset EPS that can be distressing and potentially dangerous if airway muscles are involved, but it is generally managed quickly with anticholinergic medications like benztropine or diphenhydramine.

D. Sexual dysfunction or gynecomastia – These are related to endocrine side effects from increased prolactin levels. They are bothersome and may affect adherence but are not medical emergencies.

Take-home points:

• NMS is a life-threatening complication of antipsychotic therapy and must be recognized early.
• Key warning signs include hyperthermia, autonomic instability, altered mental status, and muscle rigidity.
• Immediate drug discontinuation and emergency medical care are essential for survival.

Tardive dyskinesia (TD) is a late-onset, potentially irreversible movement disorder associated with long-term use of first-generation antipsychotics like loxapine. It is characterized by involuntary, repetitive movements, particularly of the face, lips, tongue, and sometimes the extremities. Regular monitoring using the Abnormal Involuntary Movement Scale (AIMS) is crucial for early detection and intervention.

Rationale for correct answer:

B. Tardive dyskinesia – Correct. TD often develops after months to years of antipsychotic therapy. The hallmark signs include lip smacking, tongue protrusion, chewing motions, and facial grimacing, matching the client’s AIMS findings. Early detection is important, as symptoms may become irreversible if the drug is continued.

Rationale for incorrect answer:

A. Parkinsonism – Typically presents with rigidity, bradykinesia, and tremors, resembling Parkinson’s disease. These symptoms usually appear early in treatment, not after long-term use.

C. Anticholinergic effects – These include dry mouth, blurred vision, constipation, and urinary retention. They do not explain the involuntary facial and tongue movements observed in this client.

D. Akathisia – Characterized by inner restlessness, inability to sit still, and pacing, typically occurring shortly after starting or increasing antipsychotic therapy. The client’s symptoms are distinctly involuntary movements, not restlessness.

Take-home points:

• Tardive dyskinesia is a late-onset, often irreversible adverse effect of long-term antipsychotic therapy.
• Regular AIMS assessments are essential for early detection and intervention.
• Prompt reporting of symptoms can guide the provider in adjusting therapy to prevent progression.